Perioperative Teamwork For The Patient With A Shared Airway
Perioperative Teamwork For The Patient With A Shared Airway
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication July 2016.
Perioperative teamwork
for the patient with a
shared airway: a case study
by G Jones
Correspondence address: LMT(ODP) G Jones, Royal Navy Operating Department Practitioner, Albert House, Theatres, Defence Medical Group South (DMG South), Queen Alexandra
Hospital, Cosham, Portsmouth, PO6 3LY. Email: gareth.jones345@mod.uk
As with every GA, the anaesthetist aimed to reduce the patient’s sensory
experience using the triad of anaesthesia
ASA Grade 1 Normal healthy patient (that is additional cost to the healthcare provider commented that it may only take a few
without any clinically important and were not available in the NHS trust. minutes for the effects of poor positioning to
comorbidity and without clinically have lasting effects for the patient, resulting
significant past/present medical
history) Time out in pressure sores and potentially fatal
sepsis. However, it is hard to prove a direct
ASA Grade 2 A patient with mild systemic The patient was transferred out of the relationship between position, intervention
disease anaesthetic room and into theatre. The and outcome. Best practice following local
ASA Grade 3 A patient with severe systemic ’time out’ procedure was performed protocol should be carried out by all team
disease following local protocol (NPSA 2009). members in order to reduce the risk of harm
ASA Grade 4 A patient with severe systemic The patient’s American Society of due to poor patient positioning.
disease that is a constant threat Anesthesiologists (ASA) grade was
confirmed as grade 2 (Table 3) and the
to life
Skin preparation and
locally produced patient consent form was
Table 3 American Society of Anesthesiologists analysed to confirm the patient, operative draping
(ASA) grades of anaesthesia (NICE 2016) site and procedure. Concerns highlighted As the patient’s advocate, it is the
during the team brief were reiterated, in professional responsibility of the ODP-
anatomy. This enabled the anaesthetist addition to team members being made surgical to maintain the sterile field and
to view the vocal cords from a different aware of the location of the difficult airway manage the risks of infection (AfPP 2011,
perspective (Mushambi & Francis 2013). equipment should the NIMET become HCPC 2012). Skin preparation and patient
A laryngoscope with a standard McCoy or dislodged during the procedure. The time draping requires additional consideration
McIntosh blade could have been utilized, out involves many different factors and an in head and neck surgery as the operative
however in comparison the VL provides in depth discussion is beyond the focus of site is in close proximity to non-sterile
a superior view of the glottic opening this article. anaesthetic equipment and unscrubbed
(Fitzgerald et al 2015). For patients with team members (Corbridge & Steventon
an anticipated difficult airway a flexible Patient positioning 2010). This can lead to a breach in sterility
fibreoptic scope can also be used to and failure to protect the anaesthetic
negotiate a potentially displaced larynx All team members were involved in the circuits could result in disconnection of
(Allman & Wilson 2011). Alternatively, the positioning of the patient on the operating anaesthetic tubing. Should the NIMET tube
anaesthetist could have opted to administer table. The surgeon directed the team become dislodged the surgeon may be
an inhalational induction technique, to initially position the patient in the required to halt surgery until the patient is
allowing the patient’s airway to be tested supine position with the 30 degrees neck re-intubated (Cheshire 2013). Since most
due to its gradual onset (Hardcastle 2007). extension. In order to reduce the risk of patients undergoing thyroid surgery have
Awake intubation is another option as this neck hyperextension and pressure ulcers altered anatomy this can take time resulting
would enable the patient to maintain their a gel head ring and shoulder supports in oxygen desaturation, hypoxia or even
own airway, however this has been known were placed under the patient. The patient death (Cheshire 2013). Throughout the
to increase patient anxiety levels (Cook was then tilted into reverse Trendelenburg operation, the ODP anaesthetics and ODP
& Simpson 2013). Whilst Fitzgerald et al (Elisha et al 2010). Placing the patient surgical teams worked in conjunction with
(2015) called for greater use of awake VL in reverse Trendelenburg maintains each other to ensure that the anaesthetic
techniques, Swarbrick and Turner (2015) cardiovascular stability and increases equipment was not disturbed.
advised caution since there is no guarantee drainage from the operative site (Hamlin et
that the skill of performing anaesthetised al 2009, Washington & Smurthwaite 2009).
intubation will transfer to awake intubation.
Haemostasis
Washington and Smurthwaite (2009)
Patient A was successfully intubated using suggested that teamwork between theatre Before the surgeon commenced closure he
the VL and NIMET tube. staff in positioning the surgical patient is evaluated and treated potential areas of
essential. Elisha et al (2010) recommended bleeding in order to gain haemostasis. This
The ODP-anaesthetics applied tape to close
that correct positioning should be a focus of stage of the operation required the theatre
the patient’s eyelids, in order to prevent
anaesthetic management, but responsibility team to work together under the direction
corneal abrasions which could result in a
for safe patient positioning should be of the surgeon. Here the anaesthetist was
loss of vision, and then secured padding
shared equally between all team members asked by the surgeon to create positive
over the eyes for extra protection (Allman
(Hamlin et al 2009). Poor positioning pressure inside the lungs by placing the
& Wilson 2008). Padding the eyes in head
is associated with significant morbidity patient in the Trendelenburg position. The
and neck surgery reduces the risk of eye
(Washington & Smurthwaite 2009). Correct ODP-surgical ensured all instrumentation
damage due to the close proximity of
patient positioning optimises tissue viability; was secured within the sterile field to
surgery; padding has been shown to be
cushioning under the shoulders and other prevent inadvertent desterilisation.
more effective than ointment (Corbridge
& Steventon 2010). Grixti et al (2013) bony prominences relieves pressure The anaesthetist then administered
recommended the use of bio-occlusive in addition to aiding surgical access a valsalva manoeuvre (VM). One VM
eye dressings however, these are at an (Adedeji et al 2010). Adedeji et al (2010) technique involves applying 30cm positive
>>
end expiratory pressure (PEEP) to the leave theatre. As with the other stages recovery. Oxygen was administered
anaesthetic circuit by altering the adjustable of the surgical checklist, the sign out as prescribed through a Hudson non-
pressure limiting valve. This increases is a standard template designed to be rebreathing mask. Assessment of the
internal jugular pressure causing a reflux used in all operations and therefore will patient’s breathing rate was undertaken.
of venous blood allowing active bleeding not be discussed in detail in this article Particular attention was given to the
points to be identified and cauterised or (NPSA 2009). breathing rate ensuring equal and bilateral
ligated by the surgeon (Moumoulidis et al air entry into each lung, allowing the ODP-
2010). Communication failure at this point Post anaesthetic care recovery to anticipate if the airway was
by the anaesthetic and surgical teams could becoming obstructed (Hatfield 2014).
result in a failure to maintain haemostasis It is vital that the ODP-recovery, or nurse
and blood vessels remaining open, equivalent, is competent in caring for Circulatory assessment was also used as
potentially leading to postoperative bleeding patients in the postoperative phase. They an indicator of a sign that the airway might
and placing the patient at risk of airway should be able to respond appropriately become compromised due to haemorrhage
compromise (Hobbs & Watkinson 2007). to patient incidents that may occur during at the operative site. Tachycardia and
emergence and recovery from anaesthesia hypotension may be a sign of postoperative
Pharmacological haemostatic agents (AAGBI 2013). The handover was given bleeding (Furtado 2011). Electronic
can also be applied over the RLN (for to the ODP-recovery by the anaesthetic, monitoring should be used in addition
example Surgicel®) to aid haemostasis surgical and theatre teams stating pertinent to manual observation, palpation and
whilst preventing neurological trauma from information to aid in the patient’s recovery assessment to detect haemorrhage. A
the surgical drain (Hobbs & Watkinson including medication administered and small percentage of patients who undergo
2009). Ahluwalia et al (2007) concluded closure materials used. Patient monitoring thyroid surgery have to return to theatre
that surgical drainage is not always including electrocardiogram (ECG), pulse due to postoperative haematoma (Morton
necessary in elective thyroid surgery oximeter and noninvasive blood pressure et al 2012). Untreated, a haematoma can
and can prolong hospital stay increasing were attached and the ODP recovery compress on the trachea. Whilst in the
postoperative infection risk. The surgeon conducted an initial assessment using the initial stages it may not be visible from the
in this case inserted a suction drain to ABCDE approach (Table 4). outside, any internal neck swelling could
monitor postoperative blood loss since cause breathing problems (Furtado 2011).
postoperative bleeding can result in Failure to actively monitor the patient
laryngeal oedema, haematoma and tracheal at this stage may lead to undiagnosed Furtado (2011) advised checking the edge
compression. The suction drain was complications (Hatfield 2014). Furtado of the dressing. If the dressing appears
opened prior the patient leaving theatre (2011) stresses that in thyroid surgery tight, a change in neck circumference may
(Ubhi 2003). inadequate assessment may lead to airway be an indication of swelling, which cannot
compromise and breathing difficulties. be assessed by monitoring equipment
Consideration was paid to the airway, alone. For patients undergoing a procedure
Extubation
breathing and circulation (ABC) elements with a shared airway it is important
Extubation in theatre has the benefit of of the ABCDE approach (Table 4) in the to handover the nature of the closure
having team members and emergency immediate recovery phase for the patient. materials used to the ODP-recovery. In
equipment to hand should the patient Circulation will be the main focus of this the event that the wound needs to be
experience airway difficulties. At the end of article as failure to detect haemorrhage opened urgently to remove a hematoma
the operation the anaesthetist performed can lead directly to airway and breathing compressing on the trachea, staple
a deep extubation to assess vocal cord problems. Disability and exposure were removers or suture scissors need to be
function with a standard laryngoscope performed as standard for all procedures readily available to release the closure
(O’Neill & Fenton 2008). Deep extubation, therefore will not be discussed in detail in material if required (Hobbs & Watkinson
where the ET tube is removed whilst the this article. 2007). If any of these occur this will need to
patient is still fully anaesthetised, reduces be communicated to the senior clinician for
Airway assessment was the first priority
the chance of coughing during emergence. immediate assessment (Furtado 2011).
to make sure that a patent airway was
Coughing during the immediate recovery
maintained by the patient throughout The anaesthetist informed the ODP-recovery
phase may lead to suture rupture, wound
dehiscence and oedema (Cheshire 2013). that the patient has been administered with
Suction should be readily available to dexamethasone, a corticosteroid with anti-
A – Airway emetic properties (Weir 2013). For patients
remove secretions to reduce the risk
of coughing and prevent laryngospasm B – Breathing undergoing a thyroidectomy the primary aim
(Furtado 2011). of dexamethasone administration is to help
C – Circulation
reduce the risk of laryngeal oedema (Allman
D – Disability & Wilson 2011). It is a further measure
Sign out E – Exposure to reduce the risk of pulmonary oedema
At the end of the operation the sign as outlined above to avoid intensive care
out procedure was performed in order Table 4 ABCDE approach to recovery admission or mortality post-surgery (Cook
ensure that the patient was safe to (Hatfield 2014) & Simpson 2013). It has been suggested
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